Does anyone remember the movie, The Sixth Sense? The twist, as everyone knows now is that Haley Joel Osment’s character is not just a disturbed little boy, but actually sees ghosts (really, you didn’t know? sorry), and the well-intentioned child psychiatrist played by Bruce Willis doesn’t know that he is, in fact, dead.
I always found this movie a compelling metaphor for one of the great terrors of life: that at any moment our world can radically change around us, and more terrifying still, it is possible that we may continue on, unaware of our fate until visions become nightmares, and our ignorance is confronted by a painful new reality.
There is a similar drama that plays itself out in medicine every day, where like Bruce Willis, we as the doctors with all of our training in finding and treating disease discover that the effect we are having on patients was quite different from the one we intended, and that we are in fact hurting and not helping.
As a doctor I have to live with the reality that some of my actions may have unintended consequences, but when the foundation that my actions are built on become unstable then those unintended consequences can become a nightmare.
The cognitive errors that lead to this phenomenon are many and varied, and recent medical history is full of them (radical mastectomy for breast cancer, hormone supplements for menopause, COX-2 inhibitors for pain, bisphosphonates for osteoporosis).
Another of these errors is recently well described by Dr. David Newman on his blog over at SMARTEM about the current state of affairs in the world of cardiology, and the literature supporting the use of stress tests and revascularization techniques to treat coronary artery disease.
Like all great medical empiricists, David has asked a simple question. Where is the observed benefit? In asking this question he instead unearthed a pervasive flaw in the body of evidence that cardiologists hold up daily to patients as proof that what they are doing for them is in their best interest.
The flaw, simply put is this: that an intervention for something (opening up or bypassing a clogged artery in this case) is not the same as the the something (heart attack or death from heart attack) itself. Successfully placing a stent in someone’s coronary artery does not mean you succeeded in preventing a heart attack in that patient, and equating the two may, by a certain sleight of hand, offer some impressive numbers to justify continuing to put stents in people, but they do little to reassure the patient who now has a stent in their heart that all they went through was worth it. In fact, according to David’s review of the literature.
Studies and meta-analyses have proven repeatedly that except for patients actively having a heart attack, placing stents neither saves lives nor prevents future attacks. This is a discomfiting fact that even the American Heart Association has recently conceded.(1) Furthermore, the most optimistic trial data suggest that, at best, 3 to 5% of bypass surgery patients live longer because of the operation.(2) Thus at least 19 of 20 people who have bypass surgery will not experience a life-saving benefit.
No benefit for stents unless you are actively having a heart attack? Well, at least there is some small benefit for bypass you say. But when you add up the personal cost of having your chest sawed open (time in the hospital, pain, complications, etc) just for the one in 20 chance that you may live a few months longer, the benefit seems much more questionable. David sums up the effect this cognitive error has on the practice of medicine like this:
“The great tragedy of flawed study design in research is its legacy. Instead of stress tests being a predictor of what patients care about (having heart attacks or dying), they are a predictor of an invasive, expensive, and largely fruitless techno-bangle. Instead of modern cardiac drugs being proven effective against heart attacks and death, many are effective only at preventing bad tests and unnecessary procedures. In a twisted way this seems useful too, but it’s a dishonest and ineffective approach to preventing real heart problems.”
His plea to “untangle the legacy of past research errors and…to understand and learn from them in order to prevent them in the future” seems an obvious call to reason. But will anybody listen?
I don’t believe on the whole that it is greed, lack of compassion or intelligence that perpetuates these types of errors, rather something much more frightening to us as doctors. Our version of the Sixth Sense metaphor: that perhaps without realizing it, our training has led us into a world where healing becomes harm.
For 200 years modern medical training has focused on finding and treating disease in the service of our patients. As doctors we depend on this training to see through our patients to the disease. So why wouldn’t a cardiologist, focused on atherosclerosis as the object of his attack, see revascularization as cutting through to the problem rather than a misstep of logic.
But what happens when you are forced to admit that your current field of knowledge is inadequate, and that treating disease is, in this instance, not equivalent with helping the patient. What happens if your realization of this fact places the body beyond the interventions you were trained to perform?
For many doctors this is an intolerable reality, made even worse by the thought that you might be hurting or even killing some of the people you intended to help. Better to gloss over and ignore the possibility than address it. “We’ll get to that later, I have patients to see”.
Whether we choose to delve deeply into these issues, or skirt them like inevitable ghosts in the machine living furtively in the background, they are questions that haunt all of us as doctors. I have learned to deal with it by asking myself what is it we are about as a profession?
Is the search for disease a means to an end, or is it the end in itself? Are we going to be technocrats inculcated in a belief system, or are we going to be philosophers and free thinkers; doctors who accept our cognitive errors and try to address them (no matter how jarring it may be to our worldview) in order to benefit our patients.
When we stray from the latter course, it is not because we don’t want health and healing, rather it is that to do so means having to let go of some of the comforts of 200 years of belief that disease always has an objective structure, one that we can “see” and therefore manipulate. More importantly we have made the grave error in believing that the ability to manipulate a disease process and benefiting patients are always the same thing.
I decided long ago, that while I carry the tools of modern medicine into battle against disease every day in my effort to help patients, I must understand and accept the limitations of my weapons. In doing so I hope I’m not blindly following dogma, and in turn being a better doctor to my patients. I also hope I’m a little more prepared when a new paradigm comes along to disentangle us from our current visions and the nightmare of disease. Sound crazy? Well everyone thought Haley Joel Osment’s character was crazy too.